Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA 02114, USA.
J Vasc Surg. 2011 Jun;53(6):1492-8. doi: 10.1016/j.jvs.2011.01.070. Epub 2011 Apr 22.
Type IV thoracoabdominal aortic aneurysm (TAAA) repair, despite low risk of spinal cord ischemia (SCI), is reported to have significant morbidity and mortality. This has led some to apply adjuncts (eg, extracorporeal circulation) used in more extensive TAAA repair or to consider alternative approaches, such as hybrid operations. We have used a consistent, simplified surgical approach to type IV TAAA, and the goal of the present study is to review experience over 2 decades with such treatment and to identify correlates of surgical morbidity.
All type IV repairs at Massachusetts General Hospital from January 1989 through September 2009 were evaluated for clinical features, technical operative details, and 30-day outcomes. Logistic regression identified predictors of morbidity. Survival was assessed using Kaplan-Meier analysis.
A total of 179 patients underwent type IV repair, with elective repair in 156 (87%) and urgent in 23 (13%). The clamp-and-sew technique was used for all operations, with routine hypothermic renal perfusion. Clinical features were age 73 ± 8 years, coronary artery disease in 89 (50%), and creatinine level >1.8 mg/dL defining chronic renal insufficiency (CRI) in 32 (18%). Operative reconstruction in 166 (93%) consisted of one beveled proximal anastomosis incorporating the descending thoracic aorta, celiac, superior mesenteric artery, and right renal arteries origins (mean visceral clamp time, 36 ± 12 minutes) and a side-arm graft to the left renal artery. Technical details included previous abdominal aortic aneurysm (AAA) repair in 52 (29%), operative time of 290 ± 90 min, estimated blood loss of 2.7 ± 1.4 L, and splenectomy in 57 (32%). The 30-day outcomes were death in 5 (2.8%), myocardial infarction in 6 (3.4%), hemodialysis in 5 (2.8%), and any degree of SCI in 4 (2.2%). Regression analysis identified a history of CRI as an independent predictor of postoperative complication or death (odds ratio, 3.4; 95% confidence interval, 1.4-8). Survival rates at 1, 5, and 10 years were 89% ± 2%, 62% ± 4%, and 36% ± 5%, respectively.
A simplified operative approach for type IV TAAA repair is associated with favorable perioperative results. These data refute the need for surgical adjuncts commonly applied in more extensive TAAA and indicate that the hybrid operation is an illogical posture. CRI should figure prominently in clinical decision making. Long-term survival equates that observed after routine AAA repair.
尽管脊髓缺血（SCI）的风险较低，但仍有报道称，四型胸腹主动脉瘤（TAAA）修复术具有显著的发病率和死亡率。这导致一些人应用于更广泛的 TAAA 修复的辅助手段（例如体外循环），或考虑替代方法，如杂交手术。我们一直采用一致的简化手术方法来治疗四型 TAAA，本研究的目的是回顾 20 多年来的治疗经验，并确定手术发病率的相关因素。
评估 1989 年 1 月至 2009 年 9 月期间马萨诸塞州综合医院所有四型 TAAA 修复患者的临床特征、技术操作细节和 30 天结果。逻辑回归确定发病率的预测因素。使用 Kaplan-Meier 分析评估生存情况。
共 179 例患者接受了四型修复，择期修复 156 例（87%），紧急修复 23 例（13%）。所有手术均采用夹闭缝合技术，常规低温肾灌注。临床特征为年龄 73±8 岁，89 例（50%）有冠状动脉疾病，32 例（18%）肌酐水平>1.8mg/dL 定义为慢性肾功能不全（CRI）。166 例（93%）的手术重建包括一个斜角近端吻合，包含降主动脉、腹腔干、肠系膜上动脉和右肾动脉起源（平均内脏夹闭时间为 36±12 分钟）和一个侧臂移植物至左肾动脉。技术细节包括 52 例（29%）既往有腹主动脉瘤（AAA）修复史、手术时间 290±90 分钟、估计失血量 2.7±1.4L 和 57 例（32%）脾切除术。30 天的结果是 5 例（2.8%）死亡、6 例（3.4%）心肌梗死、5 例（2.8%）血液透析和 4 例（2.2%）任何程度的 SCI。回归分析确定 CRI 史是术后并发症或死亡的独立预测因素（比值比，3.4；95%置信区间，1.4-8）。1、5 和 10 年的生存率分别为 89%±2%、62%±4%和 36%±5%。
简化的四型 TAAA 修复手术方法具有良好的围手术期效果。这些数据反驳了在更广泛的 TAAA 中应用手术辅助手段的必要性，并表明杂交手术是一种不合理的方法。CRI 应在临床决策中占据重要地位。长期生存率与常规 AAA 修复后的生存率相当。
